Basic Information
| Provider Information | |||||||||
| NPI: | 1356658843 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JAYNE | ||||||||
| FirstName: | BONNIE | ||||||||
| MiddleName: | JEAN | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 GALLOWS RD | ||||||||
| Address2: | |||||||||
| City: | FALLS CHURCH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220423300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037764001 | ||||||||
| FaxNumber: | 7037767113 | ||||||||
| Practice Location | |||||||||
| Address1: | 3300 GALLOWS RD | ||||||||
| Address2: | |||||||||
| City: | FALLS CHURCH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220423300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037764001 | ||||||||
| FaxNumber: | 7037767113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2010 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0110003357 | VA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 363A00000X | PA9105583 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA030693 | DC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 0110003357 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | C0004557 | MD | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.